• Notice of Privacy Practices

    This section of the Notice of Privacy Practices is to be removed from the rest of the pamphlet, signed by the individual and placed in their chart or record to be retained for a minimum period of 6 years or for the length of time designated to retain patient records. Should a patient refuse to sign the acknowledgement, a note to that effect must be recorded in the individual’s chart or record.

    § 164.520 Notice of privacy practices for protected health information.

    (a) Standard: notice of privacy practices. (1) Right to notice. Exceptas provided by paragraph (a)(2) or (3) of this section, an individual has a right to adequate notice of the uses and disclosures of protected health information that may be made by the covered entity, and of the individual’s rights and the covered entity’s legal duties with respect to protected health information.

    (2) Specific requirements for certain covered health care providers. A covered health care provider that has a direct treatment relationship with an individual must:

    (i) Provide the notice no later than the date of the first service delivery, including service delivered electronically, to such individual after the compliance date for the covered health care provider;

    (ii) If the covered health care provider maintains a physical service delivery site:

    (A) Have the notice available at the service delivery site for individuals to request to take with them; and

    (B) Post the notice in a clear and prominent location where it is reasonable to expect individuals seeking service from the covered health care provider to be able to read the notice; and

    (iii) Whenever the notice is revised, make the notice available upon request on or after the effective date of the revision and promptly comply with the requirements of paragraph (c)(2)(ii) of this section, if applicable.

    Page 82820 Federal Register / Vol. 65, No. 250 / Thursday, December 28, 2000 / Rules and


    Uses and disclosures of health information

    We use health information about you for treatment (diagnostic testing, prescription, referral, etc.) to ob-tain payment (submit claims and/or encounters to bill-ing services and/or clearinghouses, and/or collection agencies, etc.) for administrative purposes (reporting, utilization management, quality improvement and surveys, etc.) and to evaluate the quality of care that you receive. We may contact you to provide ap-pointment reminders or information about treatment alternatives or other health –related benefits and services that may be of interest to you.

    We may use or disclose identifiable health infor-mation about you without your authorization for sev-eral other reasons. Subject to certain requirements, we may give out health information without your authori-zation for public health purposes, for auditing purpos-es, for research studies, and for emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, we will ask for your written authorization before using or disclosing any identifia-ble health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.

    We may apply a change to our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area and in each examination room. You may also request a copy of our notice at any time. For more information about our privacy practices, contact the Privacy Officer listed below.

    Individual Rights

    You have the right, following a written request and agreed upon date and time, to look at, get a copy of or receive electronically protected health information about you that we use to make decisions about you. If you request copies, we will charge you at our cost for each page. You also have the right to receive a list of instances where we have disclosed protected health information about you for reasons other than treat-ment, payment or related administrative purposes. If you believe that information in your record is incorrect or if important information is missing, you have the right to request in writing that we amend the existing information.

    You may request in writing that we restrict and/or not use or disclose your information for treatment, pay-ment and administrative purposes except when specif-ically authorized by you, when required by law, or in emergency circumstances. We will consider your re-quest but are not legally required to agree to it.


    If you are concerned that we have violated your pri-vacy rights, or you disagree with a decision we made about access or amendment to your records, you may contact the person listed on the back page of this pamphlet. You may send a written complaint to the U.S. Department of Health and Human Services, Of-fice of Civil Rights. The person listed on the back page can provide you with the appropriate address upon request.

    Our Legal Duty

    We are required by law to protect the privacy of your information, provide this notice about our infor-mation practices, and follow the information practices that are described in this notice.

    Questions or complaints may be addressed to:

  • MM slash DD slash YYYY
  • Patient Acknowledgement

    I acknowledge that I can receive a copy of the PROVIDER NOTICE OF PRIVACY PRACTICES as required by the Health Information Portability and Accountability Act.

    I understand that upon completion of reading the notice, any questions I may have may be ad-dressed to the PROVIDER PRIVACY OFFICER.

  • MM slash DD slash YYYY
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